Why Are Doctors Hesitant To Prescribe Metformin

Influences On Prescribing Behavior In Diabetes

Influences on Prescribing Behavior in Diabetes A recent study,[ 1 ] conducted by three pharmacists and a nurse, explores why only 65% of patients with newly diagnosed type 2 diabetes (T2DM) and only 25% of people with ongoing T2DM are prescribed metformin. Although metformin is recommended as a first-line treatment for T2DM, it is still underused by clinicians who manage patients with T2DM. Using two focus groups with a total of 14 participants, including physicians, nurse practitioners, physician assistants, and pharmacists, the study explored situations in which clinicians were hesitant to prescribe or may have discontinued metformin use. These situations included renal insufficiency, heart failure, hepatic dysfunction, alcoholism, current or historical lactic acidosis, and manufacturer-listed contraindications. Despite a lack of scientific evidence supporting the precautions or contraindications to metformin use listed by the manufacturer, many clinicians were not comfortable prescribing metformin in the presence of a precautionary condition or contraindication. After a brief educational presentation about the evidence on the risks associated with metformin, the investigators r
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BLANKTIES

So sorry to hear of your experience. Sadly, it sounds like you have a bit more information about PCOS than your doctor. Hate to echo all the previous comments to change doctors, however that might be the best option. I'd humbly suggest, and agree with those who also think, it may be time for a **Reproductive Endocrinologist.**I backed into my PCOS diagnosis after having children; my OB-GYN put me on Clomid simply because I didn't ovulate regularly. And two cycles in, we conceived twins. It was only after the children were a few years old -- and 150+ pounds later -- that an Ann Landers/Dear Abby column my mother read connected the dots between my various symptoms to lead to PCOS. My OB, when presented with the option, totally agreed. She put me on oral contraceptives (to regulate hormones) and spironolactone (a diuretic to help flush excess testosterone from my system).It wasn't long after that we prepared to move to a military installation and my OB, who was trained by the military, suggested that once I was there, I seek out a "reproductive endocrinologist." I'd never heard the term before, but followed her advice. While sitting in that waiting room, I think I was part of a very small percentage of patients not already or actively trying to become pregnant.And yes, this doctor -- who in 2001 had already published articles on PCOS -- pretty immediately added metformin to the other meds I was already using. He did explain that it was an "off-label" use for it, however it was the beginning of cutting edge treatment for PCOS at the time. (With the 150+ pound weight gain, it was pretty evident I was also insulin-resistant; cell walls not allowing nutrients to pass through --> starving cells send out messages for hunger/needing nutrients --> repeat cycle)In discussing the medication change, I recall asking whether I'd continue to take the metformin IF my husband and I hoped to become pregnant again. His response sort of floored me -- so this is very much a paraphrase: In the past, we had pregnant women stop it. However, Yes, we're beginning to think it's important for the body to maintain the benefits of the metformin throughout the pregnancy. And we're likely to have fewer miscarriages then...(The miscarriage part floored me, because I'd had one AFTER the first pregnancy triggered the dormant aspects of PCOS and kicked them to the new level that included the insulin resistance. Suddenly my miscarriage was no longer an "act of God" but a failure of my body to create a conducive environment for a developing child. So, I grieved even more 5 years after the fact than I had at the time of the actual miscarriage itself.)About this same time, PCOS was a featured cover story in my husband's JAPA (Journal of Association of Physician Assistants) magazine. I read it, understood about 2/3 of it, and greatly appreciated it was a syndrome finally getting more attention. At that time, the cycle was understood -- yet it was still attempting to determine the actual starting point. (i.e. the chicken and egg scenario).A few years later, I dropped the oral contraceptive on my own (probably a mistake) and was so giddy about menstruating on a regular cycle *without* it, that I literally called my husband at work with the news. And yes, that was because of the metformin. I remained regular thereafter and, I hate to admit, felt more like "a real woman" again....More recently (and several moves later), I sought out the help of a reproductive endocrinologist again. While I'm past child-bearing (i.e. hysterectomy), I likely will be on metformin for the rest of my life. A fact pretty much confirmed at a very recent diabetes education consultation. I explained that a frustration for me was even if I lost 150+ pounds, was that I'd likely always be on the metformin and spironolactone *because of the PCOS* for the rest of my life. They agreed...Don't give up hope. There ARE other pathways out there. You'll ultimately find the one for the two of you. And yes, life's too short to continue working with a medical provider that a) doesn't listen to you and/or b) doesn't explain their decisions. Best Wishes!

MOMTOGIRLS

I totally understand the frustrating road of IF and PCOS! You want to get going and the tests take time (and $), which is a pain. But... the Dr. it being realistically thorough. Going through various levels of treatment only to find that your spouse has issues or you have complicating factors would be beyond frustrating - infact everyone here would be telling you to find a new Dr. because they should have tested you, etc. :)The tests cost money out of pocket, but you can't get proper treatment without them having a full picture of both of you.Did the Dr. say Metformin was not at all in your future?

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BELROSA

Whilst Metformin should be the primary allopathic drug of choice in treating Metformin, as supported by all the studies to date and it is ridiculous that the US has not approved it for use in PCOS, there are other options.There are plenty of natural supplements that have either a similar action to Metformin, or have been proven in clinical trials to be as effective.pcosinfo.wordpress.com/treatments/natural/They are generally cheaper than pharmaceutical medicines, with less side effects if taken appropriately.As Nyxwolfwalker said and SweetSunshine reiterated more eloquently ... not all women with PCOS have clinically present Insulin Resistance to warrant treatment with Metformin. Insulin levels can be kept in check in some instances through strict dietary and exercise changes. I would reiterate PTPHELAN's point to ensure that you do get a good workup prior to going on Metformin. As SweetSunshine said, you need to know for certain that you have a high fasting insulin level. Not glucose, but insulin. The euglycaemic clamp test is the most effective, but it's invasive, must be done in a hospital and very few practitioners will agree to do it. Ron Rosedale, Chief Medial Officer of Advanced Metabolic Laboratories I think does them, but he is in Denver Colorado.You may have more success locally getting a frequently sampled IV glucose tolerance test performed. It generally believed to provide comparable accuracy to a euglycaemic clamp.The other factor to take into consideration in whether or not Metformin will be beneficial to you or not, is the amount and type of carbohydrates you consume. From speaking with many women with PCOS (and having had a negative reaction to Metformin myself) I have come up with a hypothesis that Metformin is not helpful and may actually be detrimental to women who closely control their carbohydrate intake, eat a large percentage of fresh, unprocessed, low GI food and exercise regularly - at least once and even multiple times per day.Anyway, to end this long ramble, because it's nearly 3 am ... make sure that you have your insulin levels tested on fasting and as part of a glucose tolerance test of some description. Many GTTs only test for glucose. With PCOS it is imperative that they also check insulin levels at each interval.Did anyone mention how important appropriate amounts of sleep is in the treatment of PCOS? I truly need my head read ;) Good night.Edited by: BELROSA at: 5/31/2009 (12:54)I have a website with loads of PCOS info www.mypcos.info Please stop by!Leader of Managing PCOS Naturally www.sparkpeople.com/myspark/groups_individual.asp?gid=54257

Dr Won't Prescribe Metformin

Friend T2 since Jan 26,2009, looking for guidance I don't understand this doctor. Wasn't there some study recently that showed how metformin could help prevent diabetes in pre-diabetic people? So it seems very irresponsible for this doctor to deny you this treatment until you are "actually" diabetic per her opinion. Seems to me if your Doctor says you are "pre" Diabetic what is he/she waiting for.If you are getting readings over 140 on a consistent basis it is time to start attacking the problem.I see no reason why you should not be on 1000 mg a day (mabey 500 to start)and see what your reaction is to it.My sugar levels were never absurdly high 200 was a rare occassion for me and 140-80 norms.Metformin has changed my life so much and for the better is unbelievable.My Doctor actually just asked me if I wanted to lessen the dosage from 1500 mg a day.I walked out with a new script for 1650 a day I think he gets my point.If you monitor daily why wouldn't you want to give it a shot.What are your highest numbers? Type 2 taking Metformin XR also actos which I plan to stop.Last A1C was 6.7 2-25-09 A1c 6.1.... 8-12-09 5.9...2-2010 5.7 8-12-09 Will now take 2 1000 mg Met per day Someone, so
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fenlady

Help - I am really struggling to control my Type 2 with diet alone, and am in a wheelchair so can't exercise much. My last Hba1c was 36 (5.4). I know this is a good reading, but my weight keeps going up even so. And I'm only eating 1350 calories a day. I really think metformin would help me to control my weight as well as my blood sugars, but the doctor won't prescribe it and won't say why! Can anyone explain this - what does my Hba1c have to be before I can be offered metformin? Thanks.

ally1

I do think it depends on your blood test results

Brunneria

My surgery has to follow the rules set them by the local NHS governing body (are they still called primary care trusts, or have they changed name yet again?) - and their rule is that metformin is only prescribed to diagnosed diabetics with an hba1c above 48Some people have posted that their surgeries refuse to prescribe met until the hba1c hits 53

Variations In Metformin Prescribing For Type 2 Diabetes

Abstract Background: Reasons for suboptimal metformin prescribing are unclear, but may be due to perceived risk of lactic acidosis. The purpose of this study is to describe provider attitudes regarding metformin prescribing in various patient situations. Methods: An anonymous, electronic survey was distributed electronically to 76 health care providers across the nation. The 14-item survey contained demographic questions and questions related to prescribing of metformin for T2DM in various patient situations, including suboptimal glycemic control, alcohol use, history of lactic acidosis, and varying degrees of severity for certain health conditions, including renal and hepatic dysfunction, chronic obstructive pulmonary disease, and heart failure. Results: There were a total of 100 respondents. For suboptimal glycemic control, most providers (75%) would increase metformin from 1500 to 2000 mg daily; however, 25% would add an alternate agent, such as a sulfonylurea (18%) or dipeptidyl peptidase-4 inhibitor (7%). Although 51% of providers would stop metformin based on serum creatinine thresholds, the remainder would rely on glomerular filtration rate thresholds of <60 mL/min (15%), <3
Continue
reading >>

Popular Questions

BLANKTIES

So sorry to hear of your experience. Sadly, it sounds like you have a bit more information about PCOS than your doctor. Hate to echo all the previous comments to change doctors, however that might be the best option. I'd humbly suggest, and agree with those who also think, it may be time for a **Reproductive Endocrinologist.**I backed into my PCOS diagnosis after having children; my OB-GYN put me on Clomid simply because I didn't ovulate regularly. And two cycles in, we conceived twins. It was only after the children were a few years old -- and 150+ pounds later -- that an Ann Landers/Dear Abby column my mother read connected the dots between my various symptoms to lead to PCOS. My OB, when presented with the option, totally agreed. She put me on oral contraceptives (to regulate hormones) and spironolactone (a diuretic to help flush excess testosterone from my system).It wasn't long after that we prepared to move to a military installation and my OB, who was trained by the military, suggested that once I was there, I seek out a "reproductive endocrinologist." I'd never heard the term before, but followed her advice. While sitting in that waiting room, I think I was part of a very small percentage of patients not already or actively trying to become pregnant.And yes, this doctor -- who in 2001 had already published articles on PCOS -- pretty immediately added metformin to the other meds I was already using. He did explain that it was an "off-label" use for it, however it was the beginning of cutting edge treatment for PCOS at the time. (With the 150+ pound weight gain, it was pretty evident I was also insulin-resistant; cell walls not allowing nutrients to pass through --> starving cells send out messages for hunger/needing nutrients --> repeat cycle)In discussing the medication change, I recall asking whether I'd continue to take the metformin IF my husband and I hoped to become pregnant again. His response sort of floored me -- so this is very much a paraphrase: In the past, we had pregnant women stop it. However, Yes, we're beginning to think it's important for the body to maintain the benefits of the metformin throughout the pregnancy. And we're likely to have fewer miscarriages then...(The miscarriage part floored me, because I'd had one AFTER the first pregnancy triggered the dormant aspects of PCOS and kicked them to the new level that included the insulin resistance. Suddenly my miscarriage was no longer an "act of God" but a failure of my body to create a conducive environment for a developing child. So, I grieved even more 5 years after the fact than I had at the time of the actual miscarriage itself.)About this same time, PCOS was a featured cover story in my husband's JAPA (Journal of Association of Physician Assistants) magazine. I read it, understood about 2/3 of it, and greatly appreciated it was a syndrome finally getting more attention. At that time, the cycle was understood -- yet it was still attempting to determine the actual starting point. (i.e. the chicken and egg scenario).A few years later, I dropped the oral contraceptive on my own (probably a mistake) and was so giddy about menstruating on a regular cycle *without* it, that I literally called my husband at work with the news. And yes, that was because of the metformin. I remained regular thereafter and, I hate to admit, felt more like "a real woman" again....More recently (and several moves later), I sought out the help of a reproductive endocrinologist again. While I'm past child-bearing (i.e. hysterectomy), I likely will be on metformin for the rest of my life. A fact pretty much confirmed at a very recent diabetes education consultation. I explained that a frustration for me was even if I lost 150+ pounds, was that I'd likely always be on the metformin and spironolactone *because of the PCOS* for the rest of my life. They agreed...Don't give up hope. There ARE other pathways out there. You'll ultimately find the one for the two of you. And yes, life's too short to continue working with a medical provider that a) doesn't listen to you and/or b) doesn't explain their decisions. Best Wishes!

MOMTOGIRLS

I totally understand the frustrating road of IF and PCOS! You want to get going and the tests take time (and $), which is a pain. But... the Dr. it being realistically thorough. Going through various levels of treatment only to find that your spouse has issues or you have complicating factors would be beyond frustrating - infact everyone here would be telling you to find a new Dr. because they should have tested you, etc. :)The tests cost money out of pocket, but you can't get proper treatment without them having a full picture of both of you.Did the Dr. say Metformin was not at all in your future?

Pounds lost: 0.0

0

9.5

19

28.5

38

BELROSA

Whilst Metformin should be the primary allopathic drug of choice in treating Metformin, as supported by all the studies to date and it is ridiculous that the US has not approved it for use in PCOS, there are other options.There are plenty of natural supplements that have either a similar action to Metformin, or have been proven in clinical trials to be as effective.pcosinfo.wordpress.com/treatments/natural/They are generally cheaper than pharmaceutical medicines, with less side effects if taken appropriately.As Nyxwolfwalker said and SweetSunshine reiterated more eloquently ... not all women with PCOS have clinically present Insulin Resistance to warrant treatment with Metformin. Insulin levels can be kept in check in some instances through strict dietary and exercise changes. I would reiterate PTPHELAN's point to ensure that you do get a good workup prior to going on Metformin. As SweetSunshine said, you need to know for certain that you have a high fasting insulin level. Not glucose, but insulin. The euglycaemic clamp test is the most effective, but it's invasive, must be done in a hospital and very few practitioners will agree to do it. Ron Rosedale, Chief Medial Officer of Advanced Metabolic Laboratories I think does them, but he is in Denver Colorado.You may have more success locally getting a frequently sampled IV glucose tolerance test performed. It generally believed to provide comparable accuracy to a euglycaemic clamp.The other factor to take into consideration in whether or not Metformin will be beneficial to you or not, is the amount and type of carbohydrates you consume. From speaking with many women with PCOS (and having had a negative reaction to Metformin myself) I have come up with a hypothesis that Metformin is not helpful and may actually be detrimental to women who closely control their carbohydrate intake, eat a large percentage of fresh, unprocessed, low GI food and exercise regularly - at least once and even multiple times per day.Anyway, to end this long ramble, because it's nearly 3 am ... make sure that you have your insulin levels tested on fasting and as part of a glucose tolerance test of some description. Many GTTs only test for glucose. With PCOS it is imperative that they also check insulin levels at each interval.Did anyone mention how important appropriate amounts of sleep is in the treatment of PCOS? I truly need my head read ;) Good night.Edited by: BELROSA at: 5/31/2009 (12:54)I have a website with loads of PCOS info www.mypcos.info Please stop by!Leader of Managing PCOS Naturally www.sparkpeople.com/myspark/groups_individual.asp?gid=54257

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